'The minute I tell couples to use condoms or suggest permanent birth control, they ignore it or just change the topic.'
India has surpassed China to become the world's most populous nation with 1.4286 billion people, shows the latest United Nations data, even as UN projections estimate that the country's population is expected to grow for the next three decades after which it will begin declining.
Bihar, one of India's least developed states, had the highest fertility rate of 2.98.
State health officials estimate in Bihar's Kishanganj district, the fertility rate is 4.8 or 4.9.
Successive state governments have been aware of the population growth problem, particularly in Kishanganj, and have mounted programmes to curb it.
Besides the free distribution of condoms and birth control pills, the state pays Rs 3,000 to women who get sterilised and Rs 4,000 to men, and 500 rupees per surgery to the health workers who perform them.
Yet the results have been poor.
India's fertility rate fell to 2.0 in 2019-2021, but Bihar has the highest fertility rate with some families expecting women to have at least five children, preferably sons.
"I talk to women while they are experiencing labour pain and nudge them to undergo sterilisation immediately after delivery," said Parvati Rajak, a medical officer in one of Kishanganj's seven government health centres. "But the final choice is always made by the family."
"The state government's focus is to ensure that policy interventions percolate to the ground, its mechanisms such as free sterilisation, temporary birth control instruments are used actively," said Sanjay Kumar Pansari, director in the Bihar government's directorate of economics and statistics.
IMAGE: Zamerun Nisha, 33, lies down after giving birth while a doctor holds and cleans her newborn baby at the labour ward of a community health centre in Bahadurganj subdivision in Kishanganj district. All photographs: Anushree Fadnavis/Reuters
IMAGE: A nurse takes care of a newborn baby after the birth at a hospital in Kishanganj district.
IMAGE: A nurse holds the feet of a newborn baby after it was delivered at the labour ward of a community health centre in Bahadurganj subdivision of Kishanganj district.
IMAGE: Zamerun Nisha looks on as a doctor checks the heartbeat of her child with an ultrasound machine at the labour ward of a community health centre in Bahadurganj subdivision of Kishanganj district.
Just minutes after giving birth to her fifth child, Zamerun, who is married to mason Mohammad Wasim, 40, said she would try to secure permission from her husband to undergo sterilisation before leaving for home, who later agreed to the procedure.
"My body cannot take this pressure of having babies anymore," she told Reuters. "I have been lucky to survive each time."
IMAGE: Doctors perform sterilisation surgery on a woman at the operation theatre of a community health centre in Bahadurganj subdivision of Kishanganj district.
IMAGE: A baby is seen at the neonatal intensive care unit of a hospital in Kishanganj district.
IMAGE: Women wait outside the operation theatre of a community health centre in Bahadurganj subdivision of Kishanganj district.
IMAGE: Patients wait outside a primary health care centre in Belwa village, Kishanganj district.
IMAGE: Chandani Devi, 36, rests as her mother Ranjana Devi holds her newborn daughter at a hospital in Kishanganj district.
"For the fourth time I have had a girl...now I will wait for a few years before I try to have a boy," said Chandani Devi, 36, as she tried to fight back tears in a hospital ward after her delivery.
IMAGE: Women speak to health workers at a sterilisation camp set-up in a primary health care centre in Belwa village, Kishanganj district.
IMAGE: Block Community Mobiliser Pratima Kumari, 38, poses for a picture on her way back to the community health centre in Bahadurganj.
Kumari, a government health worker, offers condoms and birth control pills for free in the Kishanganj district and talks to the couples about birth control and the benefits of having just two children in Kishanganj, which has the highest fertility rate of any district in India, soon to be the world's most populous nation.
"The minute I tell couples to use condoms or suggest permanent birth control, they ignore it or just change the topic," Kumari told Reuters.
IMAGE: Pratima Kumari, Masera Khatun, 37, who is pregnant with her sixth child, ASHA (Accredited Social Health Activist) facilitator Shilly Kumari, 34, and Aliyara Khatun, 35, who is also an ASHA worker, talk about family planning and the different contraceptive methods available, outside Masera's house in Duadangi village, Bahadurganj subdivision.
Photographs curated by Manisha Kotian/Rediff.com
Feature Presentation: Rajesh Alva/Rediff.com